PALIC Questions 

  • Client Form

  • Will this insurance applied for replace or change any existing insurance?*
  • Is there any other health, accident, or disability insurance in force on the proposedinsured?*
  • In the past 12 months, has any person to be insured engaged in any hazardous sports or activities including racing, parachuting, rodeo riding, motorcycling, mountain climbing or scuba diving?*
  • Is any person to be insured currently under treatment or has any person to be insured been under treatment for excessive drug or alcohol abuse in the past 3 years?*
  • Within the past 4 years has any applicant used drugs, been diagnosed with or received any medical treatment, taken medication for or been advised to have a medical test for alcohol or drug abuse?*
  • In the past 12 months, has anyone proposed to be insured been diagnosed with ortreated for an injury, disease, or disorder of the back, the neck, or a joint by a member of the medical profession?*
  • Has any Applicant ever been diagnosed with or received treatment, tested positive or taken medication for any of the following conditions: Liver cirrhosis, Hepatitis B or C, insulin-diabetes and/or neuropathy, ulcerative colitis or Crohn’s, Down’s syndrome, Rheumatoid Arthritis, ALS (Lou Gehrig’s Disease), Parkinson’s, cystic fibrosis, cerebral palsy, sickle cell or aplastic anemia, transplant recipient, multiple sclerosis, muscular dystrophy, lupus, COPD, emphysema, suicide attempt, Stroke or TIA, paraplegia or quadriplegia, kidney or renal failure or been hospitalized more than 3 times in the past year?*
  • Within the past 10 years has any Applicant tested positive or been diagnosed with ortreated as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS RelatedComplex (ARC)?*
  • Within the past 10 years has any Applicant been diagnosed with, taken medication or received treatment for heart attack, coronary artery disease, or been advised to have any diagnostic tests relating to the heart or circulatory system which have not been completed or for which results have not been received?*
  • Within the past 2 years has any Applicant been treated, tested or taken medication for mitral valve prolapse, tachycardia-bradycardia or arrhythmia?*
  • Within the past 5 years has any Applicant been diagnosed with, taken medication orreceived treatment for internal cancer, leukemia, malignant melanoma or any othermalignancy or been advised to have any diagnostic tests relating to cancer which have not been completed or for which results have not been received?*
  • Within the past 4 years has any Applicant used drugs, been diagnosed with or received any medical treatment, taken medication for or been advised to have a medical test for alcohol or drug abuse?*
  • Within the past 24 months has the primary applicant used any form of tobacco (including cigars, pipe or chewing tobacco)?*
  • Is the primary applicant or any of the applicant’s dependent’s (spouse, child(ren) under age 25), whether applying for coverage or not, currently pregnant or have a pending adoption?*
  • Within the past 5 years has any applicant been diagnosed with, taken medication orbeen treated by a physician for internal cancer, malignant melanoma or any othermalignancy or been advised to have any diagnostic tests relating to cancer which have not been completed or for which results have not been received?*
  • In the past 12 months, has any applicant had an elevated or rising prostate specific antigen (PSA) or a carcinoembryonic antigen (CEA) test, abnormal mammogram, abnormal pap smear, positive for BRCA 1, 2 gene mutation, or abnormal biopsy?*
  • In the past 6 months, has any applicant been confined to a nursing facility (except for short term rehabilitation), bedridden, or been told they are disabled?*
  • Does the proposed insured, other than a spouse or a dependent, intend to reside outside the US?*
  • In the last 12 months has any applicant been diagnosed, treated or tested by a physician or taken medication for any of the following conditions and has seen a physician more than twice for any of these conditions? kidney stones, kidney/bladder or urinary infections, hepatitis A, asthma or bronchitis, sleep apnea, unoperated hernia, pituitary, thyroid, stomach, disc or back, (TMJ) temporomandibular joint, carpal tunnel syndrome, pelvic inflammatory disease, obsessive-compulsive disorder, psychosis, schizophrenia, migraines, endometriosis, uterine fibroids or uterine cyst.*
  • If any applicant had a cesarean section, more than one miscarriage or seen a physician for infertility treatment and has not had a tubal-ligation or hysterectomy and is still of childbearing age?*
  • In the last 12 months has any applicant been diagnosed, treated or tested by a physicianor taken medication for any of the following conditions?a. Emphysema and not smoking, non-insulin Diabetesb. Osteoarthritis, bariatric surgery (weight loss)-gastric bypass, stapling, or lap bandc. cataracts or glaucoma, macular degeneration,d. cardiac ablation, epilepsy-seizures, hip or knee replacemente. mitral valve prolapse, tachycardia-bradycardia or arrhythmia,*
  • In the last 12 months, have you or any applicant tested positive for Covid-19 and been hospitalized, taken medication for, or still have symptoms of Covid-19?*
  • In the last 12 months, has any applicant had an application for health insurance declined or postponed?*
  • Is there any other condition that will require a rate up?*
  • In the last 12 months, has any applicant been confined more than 2 times in a hospital, ambulatory or surgical facility?*
  • In the last 12 months, has any applicant received treatment or had a test performedwhere the results were other than normal or still pending or received treatment for any abnormal test?*
  • In the past 10 years, has any applicant been treated or diagnosed with rheumatoidarthritis, osteoarthritis, psoriatic arthritis, degenerative joint disease or any disease or disorder of the bones, joints, muscles, or the spine including the hips, knees, and elbows?*
  •  / /
  • Should be Empty: